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Suicide in Children: A Systematic Review a
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Rebecca Soole , Kairi Kõlves & Diego De Leo
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Australian Institute for Suicide Research and Prevention, National Centre of Excellence in Suicide Prevention, World Health Organization Collaborating Centre for Research and Training in Suicide Prevention, Griffith University, Australia Accepted author version posted online: 17 Dec 2014.
Click for updates To cite this article: Rebecca Soole, Kairi Kõlves & Diego De Leo (2014): Suicide in Children: A Systematic Review, Archives of Suicide Research, DOI: 10.1080/13811118.2014.996694 To link to this article: http://dx.doi.org/10.1080/13811118.2014.996694
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Suicide in Children: A Systematic Review Rebecca Soole1, Kairi Kõlves1, Diego De Leo1 1
Australian Institute for Suicide Research and Prevention, National Centre of Excellence in Suicide Prevention, World Health Organization Collaborating Centre for Research and Training in Suicide Prevention, Griffith University, Australia
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Correspondence to: Rebecca Soole, Australian Institute for Suicide Research and Prevention, Griffith University, Mt Gravatt Campus M24, Brisbane, Queensland, Australia 4111. Email: [email protected]
Abstract Objectives. To provide a review of studies on suicide in children aged 14 years and younger. Method. Articles were identified through a systematic search of Scopus, MEDLINE and PsychINFO. Key words were “children, suicide, psychological autopsy and case-study”. Additional articles were identified through manual search of reference lists and discussion with colleagues. Results. Fifteen published articles were identified, eight psychological autopsy studies (PA) and seven retrospective case-study series. Conclusion. Suicide incidence and gender asymmetry increases with age. Hanging is the most frequent method. Lower rates of psychopathology are evident among child suicides compared to adolescents. Previous suicide attempts were an important risk factor. Children were less likely to consume alcohol prior to suicide. Parent-child conflicts were the most common precipitant.
KEYWORDS: child, suicide, psychological autopsy, case series 1
INTRODUCTION Whilst there has been growing research interest in adolescent and youth suicide, few contemporary researchers have focused specifically on children (Pompili, Mancinelli, GIrardi, Ruberto & Tatareli, 2005), except through case series (Tishler, Reiss & Rhodes, 2007). Indeed, there have only been two non-systematic reviews of the literature pertaining specifically to child suicide (Dervic, Brent & Oquendo, 2008; Westefeld et al.,
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2010). Previous studies that do include children (below the age of 15 years) have predominately grouped children and adolescents by discussing prevalence, typical methods, temporal variations and other descriptive elements all together (Tishler et al., 2007). Consequently, attention to predictive factors specific for children younger than 15 years of age has been very limited.
The definitions of suicide and suicidal behaviour have often been a contentious issue within the research community (De Leo, Burgis, Bertolte, Kerkhof & Bille-Brahe, 2006). Arguably, the lack of standardised nomenclature has contributed to the under-reporting or misclassification of suicide cases, hindering reliability of data (De Leo et al., 2006). Underestimation could be especially marked in suicide cases of young individuals (Crepeau-Hobson, 2010; De Leo, 2010), affecting the validity of studies and the advancement of knowledge in prevention (De Leo et al., 2006).
One core characteristic of all definitions of suicide is the presence of intention to die. This aspect is particularly important when discussing suicide in children. In fact, children are often described as incapable to cognitively understand death or “estimate degrees of
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lethality or outcomes of their self-destructive acts” (Pfeffer, 1997, p. 553), and as such they have often been precluded from deliberately engaging in suicidal behaviour. However, empirical evidence suggests that most children have an understanding of both death and the concept of suicide by the age of eight (Mishara, 1998) and many of them are capable of planning, attempting and dying by suicide (Pfeffer, 2000; Tishler et al., 2007). Indeed, historical investigations of early modern England suggest that suicide
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during childhood represented a much larger proportion of total suicides than it does today (Murphy, 1986).
Childhood as a distinct life period was not widely recognised until the last two centuries (Aries, 1962/1973). However, Hockey and James (2003) discern that age is now pivotal in the characterisation of a child. The Oxford Dictionary (n.d.) defines a child as “a young human being below the age of puberty or below the legal age of majority”. Within research, the tendency to define ‘children’ as younger than 15 years stems from the consensus to group statistics in age bands of 5 years. Guided by this, this review distinguishes children from adolescents and defines a child as an individual younger than 15 years of age.
Several research methods are employed in the field of suicidology. One of the most widely used methods is the psychological autopsy (PA), which involves interviewing those close to the deceased (Knoll, 2008). Reviewing coronial records is also frequently adopted in suicidology. Both these methods are involved in the studies included in this
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systematic review, the main target of which is investigating the individual, family related and socio-environmental and contextual factors related to child suicide.
METHOD Search Methodology This systematic review was conducted using the principles of the PRISMA statement
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(Moher, Liberati, Tetzlaff, Altman, & The PRISMA group, 2009). A visual representation of the identification, screening, eligibility assessment, and inclusion of studies is presented in Figure 1. The electronic search of databases Scopus, MEDLINE via Ovid) and PsychINFO (via EBSCOHOST) was conducted in December 2013 and literature sourced from 1966 to present. The search retrieved articles containing the following key words: child(ren) AND suicide AND ‘psychological autopsy’ in all fields and child(ren) AND suicide AND ‘case-study’ in all fields. The initial database search retrieved a total of 5,383 articles (Scopus n = 5,151, MEDLINE n = 108, PsychINFO n = 124).
Inclusion And Exclusion Criteria The exclusion of non-English articles (n = 288) reduced the total number to 5,095. The within search functions allowing the specification of population age (limit to child[hood]) and keywords further reduced the total number of articles retrieved through database searching to 449 (Scopus n = 302, MEDLINE n = 87, PsychINFO n = 60). After duplicates were removed (n = 71), a total of 378 articles were included in the screening process.
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Abstracts and titles were initially screened using the following eligibility for inclusion criteria: 1) article describes a primary research study (with the exception of previous meta-analyses and systematic reviews), 2) methodology applied is the psychological autopsy method or retrospective case series and sample consists of children, 3) study outcome focused on suicide (exclusion of non-fatal suicidality, that is, attempted suicide
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and suicidal ideation). This stage of initial screening eliminated a total of 243 nonrelevant articles.
Full text articles (n = 135) were assessed using the following additional criteria: 1) data sources were clearly stated and reliable; and, 2) sample included specifically children aged 14 years and younger or separated children and adolescents in analyses. Studies that included children together with adolescents during analysis and discussion, thus preventing information specific to children to be extracted, were excluded. Four exceptions were the psychological autopsy studies by Brent and colleagues (1999), Marttunen and colleagues (1991) and Shaffer and colleagues (1996), and the retrospective case study by Weinberger and colleagues (2001), which defined children as individuals aged 16 years and younger. Although this age cut-off deviates from the previously defined age-bracket for ‘child’, these studies were deemed near enough to the population we wanted to investigate. Conversely, two studies with very small sample sizes (n = ≤13) presenting very limited descriptive information (only figures by gender and suicide methods) were excluded (Ağritmiş, Yayci, Çolak & Aksoy, 2004; Goren, Gurken, Tirasci & Ozen, 2003).
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RESULTS A limited number of studies (n=12) have investigated suicide in children, either as a separate population or as a subsample. Several articles (n=7) compared children who died by suicide with adolescents. The 15 articles included in this review, consisted of eight studies employing psychological autopsy methodology and seven retrospective case-
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study series. Table 1 presents a summary of the 15 published articles (from 12 studies).
Five psychological autopsy studies included a control group utilizing either a living community sample matched on demographic characteristics, or accidental deaths. Only three studies consisted of just children aged 15 years and younger (from five published articles), while the remaining studies analysed children and adolescents separately or compared child suicides with adolescent suicides in analysis. With the exception of Beautrais’ study (2001b), which consisted of 61 child suicides, the number of children in samples was small, generally less than 50 cases. Youngest age of child in these studies was 8 (Grøholt & Ekeberg, 2003) and 9 years old (Beautrais, 2001b). All studies were conducted in developed countries, including New Zealand, Turkey, Singapore, England, Hong Kong, Finland, with Norway and the USA.
Several key findings were identified. Suicide incidence and gender asymmetry increases with age and hanging is a frequently employed method of suicide by children. Compared to adolescents who die by suicide, lower rates of psychopathology are evident among child suicides and children consume alcohol less frequently prior to suicide. Parent-child
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conflict appears to be a salient precipitating factor for children. In addition, previous suicidal behaviour is a pertinent factor in child suicide.
DISCUSSION Demographics Suicide incidence increases with age. Shaffer and colleagues (1996) suggested that this
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increase may be partly explained by developmental trajectories of important risk factors, such as psychopathology, which is more common in later adolescents. Some gender disparity seems to exist in regards to child suicide, with studies reporting that more suicide deaths occur among male children (Beautrais, 2001b; Freuchen, Kjelsberg & Grøholt, 2012a). However, Shaffer (1996) argues that gender asymmetry becomes more apparent with increasing age. Gender-related method preferences may be an underlying reason for the observed gender disparity, with males significantly more likely to use more lethal methods of suicide compared to females (Brent, Baugher, Bridge, Chen & Chiappetta, 1999; Shaffer, 1974).
Prior research has shown that suicide within Indigenous populations is proportionately more frequent than in non-Indigenous populations (De Leo, Sveticic, Milner & McKay, 2011), and this aspect is particularly visible in children. In a 10-year retrospective study, Beautrais (2001b) examined the epidemiology of New Zealand children who had died aged less than 15 years. She found that Indigenous children predominated child suicide with almost 60% of suicides occurring among Maori’s.
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Suicide Circumstances Of the ten studies (out of 12) which identified predominant suicide method, children were found to use hanging most frequently in five studies. A number of geographical and temporal variations were observed. For example, in the USA, firearm suicides (Brent et al., 1999; Coskun, Zoroglu & Ghaziuddin, 2012; Weinberger, Sreenivasan, Sathyavagiswaran & Markowitz, 2001) were found to surpass hanging cases, while
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jumping from a height was most common in Hong Kong (Lau, 1994) and Singapore (Loh, Tai, Ng, Chia & Chia, 2012). These characteristics mirror older cases in those countries. Access to guns has been identified as an additional and pertinent environmental factor in suicide risk. Miller and colleagues (2002) found a positive and statistically significant association between gun availability and suicide in children aged 5-14 years in the USA. Results suggested that children who lived in states with the highest access to guns were two-times more likely to die from suicide and, importantly, seven-times more likely to use a firearm (Miller, Azrael & Hemenway, 2002). Almost forty years ago, Shaffer (1974) reported that the most common method employed by children was carbon monoxide poisoning, a leading suicide method in England and Wales at that time (Kreitman, 1976). In studies that included age-group comparisons, children were significantly more likely to die by hanging than their older counterparts who used more varying methods (Grøholt, et al., 1998; Hoberman & Garfinkel, 1988). Suicide site for children was most frequently the child’s usual residence. Interestingly, Freuchen and colleagues (2012a) found female children more frequently suicided within their home (67%), compared to male children (33%), who more frequently died ‘elsewhere’ (47% compared to 25% of females).
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Individual Factors Personality Traits Several personality traits appear to be characteristic of children who died by suicide. In his classic study, Shaffer (1974) examined all suicides of children younger than 15 years of age in England and Wales that had occurred between 1962 and 1968. In his final sample of 30 children (70% male, 30% female), Shaffer (1974) systematically reviewed
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coroner reports, educational records, medical and psychiatric records and social service records when applicable. Shaffer’s (1974) study illustrated two distinct “personality stereotypes”:
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Children, who were exceedingly intelligent, socially isolated, with mothers who
had psychiatric issues; and, b)
Children who were aggressive, mistrustful, and sensitive to criticism.
Similarly, Hoberman and Garfinkel (1998) reported that, compared to adolescents who had died by suicide, children were more likely to be described as angry, nervous and impulsive. In addition, children were reported as being more withdrawn, passive and uncommunicative compared to adolescents who had died by suicide (Lau, 1994). However, the generalisability of these studies is limited due to the small samples involved and it is unknown if these traits are characteristic of all children and adolescents in these countries. More recently, Freuchen and colleagues (2012b) found children who died by suicide were significantly more ‘vulnerable and touchy’ and ‘impulsive and temperamental’ compared to children who died by accidental deaths. There was also a
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tendency for children who died by suicide to be described as ‘worried’ compared to those children who died in accidents, though this failed to reach significance.
Mental Health Or Behavioural Difficulties Adult suicide has been shown to commonly occur in the context of a pre-existing (and/or co-morbid) mental health disorders (Bertolote, Fleischmann, De Leo & Wasserman,
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2004; Cavanagh et al., 2003). However, children who die by suicide have lower rates of psychopathology. In the majority of reviewed studies, up to one third of children who died by suicide had a detectable mental health issue at time of death (Beautrais, 2001b; Freuchen et al., 2012a, Freuchen, Kjelsberg, Lundervold & Grøholt, 2012b). In contrast, Brent and colleagues (1999) found a greater prevalence of psychopathology, reporting that 60% of children who died by suicide met the criteria for psychiatric diagnosis. However, in this study the sample of children who died by suicide was a bit older (up to 16 years old).
Specifically, children with affective disorders, disruptive disorders/conduct disorders, and substance abuse disorders may be more likely to exhibit suicidal behaviour than children without these psychiatric difficulties (Brent et al., 1999; Freuchen et al., 2012a, Freuchen et al., 2012b; Grøholt et al., 1998). However, these disorders are more frequent in suicide cases of adolescents (Grøholt et al., 1998; Loh et al., 2012; Marttunen, Aro, Henriksson & Lönqvist, 1991; Shaffer et al., 1996). Brent and colleagues (1999) found that psychopathology, particularly substance abuse (single diagnosis or in the context of comorbidity with mood disorders) was found more frequently, and conveyed a higher
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suicide risk in adolescents compared to children. The prevalence of developmental disorders, specifically Attention Deficit Hyperactivity Disorder (ADHD) was relatively low (Grøholt et al., 1998; Marttunen et al., 1991; Shaffer et al., 1996). However, a literature review found that young people, particularly males, with ADHD have significantly higher risk of suicide (James, Lai & Dahl, 2004).
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Contact With Services Only three studies reported whether children had received mental health evaluation or treatment prior to death. Overall, Beautrais (2001b) reported that less than one fifth (16.4%) of children had been in contact with services in the year prior to death. Furthermore, contact with services was more common in female children (29.4%) than in males (11.4%). In the study by Freuchen and colleagues (2012b), children who died by suicide received help from school psychology services or child and adolescent psychiatry services in a similar manner (17% and 12% respectively). Interestingly, contact with services was similar for children who died in accidents (Freuchen et al., 2012b). In a Norwegian study, Grøholt and colleagues (1998) reported that over a quarter of children (29%) had received psychiatric treatment (compared to 23% of adolescents) prior to death.
Prior Suicidal Behaviour Children who died by suicide were found to have made a previous suicide attempt significantly more frequently compared to children who died in accidents (Freuchen et al., 2012a) and living control groups (Brent et al., 1999; Freuchen et al., 2012b). Between
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one-fifth and a little over one-third of children have made a prior suicide attempt (Brent et al., 1999; Loh et al., 2012; Weinberger et al., 2001). In contrast, Freuchen and colleagues (2012a) found that only 12% of children in their sample had previously attempted suicide. Nonetheless, this finding was significant in comparison to children who died in accidents, implicating prior suicide attempt as an important risk factor. A prior suicide attempt has been found to be significantly more likely in female children
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compared to male children (Weinberger et al., 2001) and in children who leaved suicide notes compared to those who do not (Freuchen & Grøholt, 2013).
Moreover, suicidal children aged twelve years and younger, have been found to think and dream about death, and this preoccupation with death has been found to be significantly correlated with the degree of lethality in subsequent suicidal behaviour (Pfeffer, Conte, Plutchik & Jerrett, 1979). Indeed, Freuchen and colleagues (2012a) found that almost half of the children in their study who had died by suicide had previously displayed an interest in suicide. These findings suggest that suicidal communication in any form among children would need to be taken seriously, requiring immediate attention. Compared to adolescents, children have been found to be significantly less likely to have expressed prior suicide ideation and made suicide attempts (Grøholt et al., 1998; Hoberman & Garfinkel, 1988). However, parents indicated that their children displayed altered behaviour prior to suicide (Freuchen et al., 2012).
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Family Related Factors Family Psychopathology Psychopathologies in the family, such as parental mood and personality disorders and substance abuse, have been demonstrated to increase child and adolescent risk for nonfatal suicidal behaviour (King, 2009; Pfeffer, Jiang & Kakuma, 2000; Pfeffer, Normindin & Kakuma, 1994). Evidence of a relationship between fatal suicidal behaviour in children
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and presence of psychiatric conditions in the family is lacking. Only one study here reviewed addressed mental health issues within the family. Shaffer (1974) found that over half of the children who died by suicide had family members experiencing psychiatric problems; however these problems also included suicide attempts made by parents or siblings of children (who had died by suicide). King (2009) points out that future research is required in order to delineate the mediating influence that shared genetic risk for psychopathology and the impact of negative family environment have on the familial transmission of both psychopathology and suicidal behaviour.
Family Suicidality Previous suicidal behaviour within the family has been demonstrated to be a predictive factor for suicidal behaviour (King, 2009; Pfeffer et al., 1994). Thirteen per cent of the children who had died by suicide in the Shaffer’s study (1974) had had a suicide attempt by a family member. Compared to children who had died in accidents, children who died by suicide were significantly more likely to have been exposed to a suicide within their community or family (2% vs. 43% respectively; Freuchen, Kjelsberg & Grøholt, 2012a).
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Brent and colleagues (2002) examined the idea of the familial transmission of suicidal behaviour among depressed adults who had attempted suicide (defined as an action made with intent to die which resulted in medical evaluation or treatment) and depressed adult non-attempters and their respective biological children. While children younger than 15 years of age were not examined separately in their analysis, the overall results suggested that children who had parents with a history of suicide attempts had a “6-fold increased
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risk for suicide attempt, relative to offspring of non-attempters” (Brent et al., 2002, p. 805). Furthermore, in a reanalysis of the same data, children who had a parent and sibling with previous suicidal behaviour were found to be at a heightened risk for suicidal behaviour at an earlier age than children without the presence of suicidal behaviour in their family (Brent et al., 2003). More recently, Spiwak and colleagues (2011) found that people exposed to both suicide attempt and suicide of a parent or guardian during childhood were significantly more likely to self-report a suicide attempt of their own than individuals without such exposure. Furthermore, these significant findings remained after the authors controlled for demographic variables, psychiatric disorders and adverse childhood events. Importantly, this study was conducted with a large sample (N = 34,653).
Parental Divorce Beautrais (2001b) found that almost half of the children who died by suicide lived in single parent or stepparent families. The implications of a non-intact family were not replicated in Norway in studies by Grøholt and colleagues (1998) and Freuchen and colleagues (2012b), who found that children who died by suicide more often lived with
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both biological parents (64% and 71%, respectively). Arguably, any association between parental separation/divorce and suicide is greatly mediated by other psychosocial factors (Gould, Greenberg, Velting & Shaffer, 2003).
Parent-Child Relationship Communication between parents and children who died by suicide was found to be
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significantly poorer compared to children who died by accidents (Freuchen et al., 2012b). In additional analyses comparing suicide note writers and non-note writers from data obtained in their psychological autopsy study, Freuchen and Grøholt (2013) found a nonsignificant trend toward note writers having poorer communication with parents compared to those who did not leave a suicide note. Gould and colleagues (2003) highlighted the need to consider the potentially negative implications of an individual’s underlying psychological difficulties on relationships and communication. However, the association between poor communication with parents and suicide has been demonstrated to persist even when the presence of psychiatric disorders was taken into account (Gould, Fisher, Parides, Flory & Shaffer 1996).
Adverse Life Events And Home Environment A detrimental home environment has the potential to greatly influence suicidality in children (Tishler et al., 2007). Adverse events, such as physical and sexual abuse, witnessing or experiencing violence, and a history of maltreatment are all potential risk factors for suicidal behaviour (Tishler et al., 2007; Séguin, Renaud, Lesage, Robert &
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Turecki, 2011). A lifetime history of abuse was found to convey a much increased risk for suicide in children (Brent et al., 1999).
The most commonly reported precipitant among children who died by suicide was family conflict, in particular parent-child conflict. Parent-child conflicts seem to be a salient precipitating factor for children (Brent, et al., 1999; Beautrais, 2001b; Coskun et al.,
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2012; Freuchen et al., 2012a; Hoberman & Garfinkel, 1998; Loh et al., 2012; Weinberger et al., 2001). These conflicts were often deemed as ‘minor’ by parents at the time (Freuchen et al., 2012a). Parent-child conflict also appears more frequently in cases of children compared to adolescents, who more frequently experience romantic relationship issues (Coskun et al., 2012; Grøholt et al., 1998; Hoberman & Garfinkel, 1988; Loh et al., 2012).
Other psychosocial predictive factors associated with child suicide include emotional interpersonal loss caused by death or separation (Beautrais, 2001b; Freuchen et al., 2012a; Freuchen et al., 2012b). Of note is that some precipitants occurred in the context of a real or perceived disruption or transition in the child’s living or educational arrangements or in the context of serious family issues (Beautrais, 2001b).
Socio-Environmental And Contextual Factors School Related Factors School-related psychosocial predictive factors include bullying, negative peer pressure, and perceived or real school performance problems. Compared to a living control group,
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children who died by suicide were found to be have experienced significantly more bullying; however, no significant differences were found compared to children who died by accidental death (Freuchen et al., 2012b). Bullying is a detrimental problem affecting some children and experiences of bullying has been implicated in suicide attempts later in life (Klomek et al., 2009). Klomek and colleagues (2009) found that boys who experienced bullying at age 8 displayed an increased risk of suicide (up to age 25 years)
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if they were also experiencing depression or conduct disorder. For girls, this increased risk remained irrespective of these mental health difficulties.
Perceived or real school performance problems were another important precipitant identified in child suicide (Coskun et al., 2012; Hoberman & Garfinkel, 1988; Loh et al., 2012). Compared to adolescents who died by suicide, children who died by suicide were significantly more likely to experience academic failure or difficulties as a precipitating event to suicide (Hoberman & Garfinkel, 1988; Loh et al., 2012). In addition, Shaffer’s (1974) study revealed that an absence from school was a common occurrence in children younger than 15 years old who died by suicide. Although children were not analysed separately, in a study conducted by Gould and colleagues (1996), children and adolescents who were neither employed or at school at the time of their death had a heightened risk for suicide compared to a control group. These findings suggest that social isolation may be associated with suicidal behaviour (Gould et al., 1996).
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Alcohol Consumption Prior To Suicide In addition to overall alcohol and substance abuse being less common in children compared to adolescents (Marttunen et al., 1991; Shaffer et al., 1996) children have been demonstrated as consuming alcohol significantly less frequently prior to death compared to adolescents (Brent et al., 1999; Grøholt et al., 1998).
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Suicide Notes There is some empirical evidence suggesting that children do not customarily leave suicide notes (Batalis & Collins, 2005; Schmidt, Müller, Dettmeyer, & Madea, 2002). Freuchen and Grøholt (2013) procured 23 suicide notes (left by 18 children) during a psychological autopsy on 42 children who had died by suicide. The number of children who left notes was high (43%) compared to findings by Grøholt and colleagues (1998) in a previous Norwegian study (14%). Freuchen and Grøholt (2013) findings are comparable to the findings of Beautrais (2001b; 32.8%), Weinberger and colleagues (2001; 37%) and Loh and colleagues (2012; 50%). The aim of Freuchen and Grøholt (2013) study was two-fold: to assess the differences and similarities between children who left suicide notes and those who did not, and to explore and describe the themes present in the notes. Overall, no differences were revealed for demographic factors, psychiatric wellness, treatment received, stressful life events or circumstances of suicide between children who left suicide notes and those who did not. Children who left suicide notes were, however, significantly more likely to have previously attempted suicide and were significantly more likely to display altered behaviour prior to suicide. Altered behaviour included being described as more joyful, affectionate, relaxed, tense or silent.
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Freuchen and Grøholt (2013) argued that the suicide notes gave an overall impression of higher suicidal intent compared to non-note writers, extending beyond the presence of a suicide note. Several themes were described by the authors, chiefly explanations for the suicide, declarations of love and post-humorous instructions.
CONCLUSION
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Suicide is a complex and multifaceted behaviour, which has not yet been extensively examined among children. Existing studies have especially been limited by relatively small sample sizes and conducted in developed countries. The retrospective nature of the PA case series, and the potentially confounding influence of the passing of time on the reliability and validity of participant recall also represent a potential limitation (Brent, Perper, Kolko & Zelenak, 1988). The parallel inclusion of a comparison group in studies would minimise this potentially confounding factor.
In addition to psychiatric factors, an interaction of psychosocial, environmental, and contextual factors seem to be associated with suicide in childhood. Evidence-based knowledge of the myriad aspects of child suicide is crucial to the understanding of child suicide and the development of targeted suicide prevention. There are few recent systematic literature reviews focusing on evidence in suicide prevention activities in children and adolescents (e.g., De Silva et al, 2013). Recognition, referral and subsequent effective treatment of psychiatric difficulties and suicidal behaviour are essential. However, lower rates of psychopathology among children who die by suicide highlights the importance of other prevention initiatives such as restriction of means and psycho-
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education for parents, peers and school staff. In addition to understanding and mitigating the risk factors associated with child suicide, a better understanding of protective factors is required.
COMPETING INTERESTS
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Nothing to declare.
FUNDING This study is supported by the Australian Research Council Linkage grant “Trends and predictors of suicide in Australian children” (LP0990918). We would like to acknowledge our partners: the Commission for Children and Young People and Child Guardian (CCYPCG), Queensland Department of Justice, Office of State Coroner (OSC); Queensland Health (QH) and; Department of Education, Training and Employment (DETE).
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Murphy, T. R. (1986). “Woful childe of parents rage”: Suicide of children and adolescents in early modern England, 1507-1710. The Sixteenth Century Journal, 17, 259-270. Pfeffer, C. R. (1997). Childhood suicidal behaviour: A developmental perspective. Psychiatric Clinics of North America, 20, 551-562. Pfeffer, C. R. (2000). Suicidal behaviour in children: from the 1980’s to the new
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Westefeld, J. S., Bell, A., Bermingham, C., Button, C., Shaw, K., Skow, C., Stinson, R. D., & Woods, T. (2010): Suicide among preadolescents: A call to action. Journal of Loss
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and Trauma: International Perspectives on Stress & Coping, 15, 381-407.
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Table 1. Studies examining suicide in children 14 years and younger Study
Country and Sample (Age Comparison Suicide Timeline
[years,
group (Age
range] and
[years,
n)
range] and
Precipitant
Psychiatric or behavioural
method
difficulties
Prior suicidal behaviour
Other important findings
--
Number of suicides seems to be increasing
n) Retrospective Case Studies Beautrais (2001b) New Zealand
9-14
No
Hanging
Argument with 23% Mental health problems
n = 61
comparison
(78.7%)
a family
within a year of death
Incidence of suicide increases with age for
member
1 in 3 known to school, mental
both males and females, with twice as many
(70.5%) and/or
health and/or social welfare
suicides among 14 year olds (57.4%) than
disciplinary
authorities
13 year olds (26.2%)
issue (26.2%)
Overall, 16.4% had contact
Majority of suicides were male (72.1%)
Bereavement
with services in year prior to
57.4% of individuals who suicided were
of immediate
death; more commonly
Maori (64.7% of females and 54.6% of
family (1 in 7)
females (29.4%; compared to
males who suicided were Maori)
11.4% of males)
Majority occurred in deceased residence
group
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1989-1998
(86.9%) 32.8% left suicide notes 9.8% family history of suicide 45.9% lived in single parent or stepparent families followed by 32.8% in nuclear families Coskun, Zoroglu
Turkey &
Archives of Suicide Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usui20
Suicide in Children: A Systematic Review a
a
Rebecca Soole , Kairi Kõlves & Diego De Leo
a
a
Australian Institute for Suicide Research and Prevention, National Centre of Excellence in Suicide Prevention, World Health Organization Collaborating Centre for Research and Training in Suicide Prevention, Griffith University, Australia Accepted author version posted online: 17 Dec 2014.
Click for updates To cite this article: Rebecca Soole, Kairi Kõlves & Diego De Leo (2014): Suicide in Children: A Systematic Review, Archives of Suicide Research, DOI: 10.1080/13811118.2014.996694 To link to this article: http://dx.doi.org/10.1080/13811118.2014.996694
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Suicide in Children: A Systematic Review Rebecca Soole1, Kairi Kõlves1, Diego De Leo1 1
Australian Institute for Suicide Research and Prevention, National Centre of Excellence in Suicide Prevention, World Health Organization Collaborating Centre for Research and Training in Suicide Prevention, Griffith University, Australia
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Correspondence to: Rebecca Soole, Australian Institute for Suicide Research and Prevention, Griffith University, Mt Gravatt Campus M24, Brisbane, Queensland, Australia 4111. Email: [email protected]
Abstract Objectives. To provide a review of studies on suicide in children aged 14 years and younger. Method. Articles were identified through a systematic search of Scopus, MEDLINE and PsychINFO. Key words were “children, suicide, psychological autopsy and case-study”. Additional articles were identified through manual search of reference lists and discussion with colleagues. Results. Fifteen published articles were identified, eight psychological autopsy studies (PA) and seven retrospective case-study series. Conclusion. Suicide incidence and gender asymmetry increases with age. Hanging is the most frequent method. Lower rates of psychopathology are evident among child suicides compared to adolescents. Previous suicide attempts were an important risk factor. Children were less likely to consume alcohol prior to suicide. Parent-child conflicts were the most common precipitant.
KEYWORDS: child, suicide, psychological autopsy, case series 1
INTRODUCTION Whilst there has been growing research interest in adolescent and youth suicide, few contemporary researchers have focused specifically on children (Pompili, Mancinelli, GIrardi, Ruberto & Tatareli, 2005), except through case series (Tishler, Reiss & Rhodes, 2007). Indeed, there have only been two non-systematic reviews of the literature pertaining specifically to child suicide (Dervic, Brent & Oquendo, 2008; Westefeld et al.,
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2010). Previous studies that do include children (below the age of 15 years) have predominately grouped children and adolescents by discussing prevalence, typical methods, temporal variations and other descriptive elements all together (Tishler et al., 2007). Consequently, attention to predictive factors specific for children younger than 15 years of age has been very limited.
The definitions of suicide and suicidal behaviour have often been a contentious issue within the research community (De Leo, Burgis, Bertolte, Kerkhof & Bille-Brahe, 2006). Arguably, the lack of standardised nomenclature has contributed to the under-reporting or misclassification of suicide cases, hindering reliability of data (De Leo et al., 2006). Underestimation could be especially marked in suicide cases of young individuals (Crepeau-Hobson, 2010; De Leo, 2010), affecting the validity of studies and the advancement of knowledge in prevention (De Leo et al., 2006).
One core characteristic of all definitions of suicide is the presence of intention to die. This aspect is particularly important when discussing suicide in children. In fact, children are often described as incapable to cognitively understand death or “estimate degrees of
2
lethality or outcomes of their self-destructive acts” (Pfeffer, 1997, p. 553), and as such they have often been precluded from deliberately engaging in suicidal behaviour. However, empirical evidence suggests that most children have an understanding of both death and the concept of suicide by the age of eight (Mishara, 1998) and many of them are capable of planning, attempting and dying by suicide (Pfeffer, 2000; Tishler et al., 2007). Indeed, historical investigations of early modern England suggest that suicide
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during childhood represented a much larger proportion of total suicides than it does today (Murphy, 1986).
Childhood as a distinct life period was not widely recognised until the last two centuries (Aries, 1962/1973). However, Hockey and James (2003) discern that age is now pivotal in the characterisation of a child. The Oxford Dictionary (n.d.) defines a child as “a young human being below the age of puberty or below the legal age of majority”. Within research, the tendency to define ‘children’ as younger than 15 years stems from the consensus to group statistics in age bands of 5 years. Guided by this, this review distinguishes children from adolescents and defines a child as an individual younger than 15 years of age.
Several research methods are employed in the field of suicidology. One of the most widely used methods is the psychological autopsy (PA), which involves interviewing those close to the deceased (Knoll, 2008). Reviewing coronial records is also frequently adopted in suicidology. Both these methods are involved in the studies included in this
3
systematic review, the main target of which is investigating the individual, family related and socio-environmental and contextual factors related to child suicide.
METHOD Search Methodology This systematic review was conducted using the principles of the PRISMA statement
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(Moher, Liberati, Tetzlaff, Altman, & The PRISMA group, 2009). A visual representation of the identification, screening, eligibility assessment, and inclusion of studies is presented in Figure 1. The electronic search of databases Scopus, MEDLINE via Ovid) and PsychINFO (via EBSCOHOST) was conducted in December 2013 and literature sourced from 1966 to present. The search retrieved articles containing the following key words: child(ren) AND suicide AND ‘psychological autopsy’ in all fields and child(ren) AND suicide AND ‘case-study’ in all fields. The initial database search retrieved a total of 5,383 articles (Scopus n = 5,151, MEDLINE n = 108, PsychINFO n = 124).
Inclusion And Exclusion Criteria The exclusion of non-English articles (n = 288) reduced the total number to 5,095. The within search functions allowing the specification of population age (limit to child[hood]) and keywords further reduced the total number of articles retrieved through database searching to 449 (Scopus n = 302, MEDLINE n = 87, PsychINFO n = 60). After duplicates were removed (n = 71), a total of 378 articles were included in the screening process.
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Abstracts and titles were initially screened using the following eligibility for inclusion criteria: 1) article describes a primary research study (with the exception of previous meta-analyses and systematic reviews), 2) methodology applied is the psychological autopsy method or retrospective case series and sample consists of children, 3) study outcome focused on suicide (exclusion of non-fatal suicidality, that is, attempted suicide
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and suicidal ideation). This stage of initial screening eliminated a total of 243 nonrelevant articles.
Full text articles (n = 135) were assessed using the following additional criteria: 1) data sources were clearly stated and reliable; and, 2) sample included specifically children aged 14 years and younger or separated children and adolescents in analyses. Studies that included children together with adolescents during analysis and discussion, thus preventing information specific to children to be extracted, were excluded. Four exceptions were the psychological autopsy studies by Brent and colleagues (1999), Marttunen and colleagues (1991) and Shaffer and colleagues (1996), and the retrospective case study by Weinberger and colleagues (2001), which defined children as individuals aged 16 years and younger. Although this age cut-off deviates from the previously defined age-bracket for ‘child’, these studies were deemed near enough to the population we wanted to investigate. Conversely, two studies with very small sample sizes (n = ≤13) presenting very limited descriptive information (only figures by gender and suicide methods) were excluded (Ağritmiş, Yayci, Çolak & Aksoy, 2004; Goren, Gurken, Tirasci & Ozen, 2003).
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RESULTS A limited number of studies (n=12) have investigated suicide in children, either as a separate population or as a subsample. Several articles (n=7) compared children who died by suicide with adolescents. The 15 articles included in this review, consisted of eight studies employing psychological autopsy methodology and seven retrospective case-
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study series. Table 1 presents a summary of the 15 published articles (from 12 studies).
Five psychological autopsy studies included a control group utilizing either a living community sample matched on demographic characteristics, or accidental deaths. Only three studies consisted of just children aged 15 years and younger (from five published articles), while the remaining studies analysed children and adolescents separately or compared child suicides with adolescent suicides in analysis. With the exception of Beautrais’ study (2001b), which consisted of 61 child suicides, the number of children in samples was small, generally less than 50 cases. Youngest age of child in these studies was 8 (Grøholt & Ekeberg, 2003) and 9 years old (Beautrais, 2001b). All studies were conducted in developed countries, including New Zealand, Turkey, Singapore, England, Hong Kong, Finland, with Norway and the USA.
Several key findings were identified. Suicide incidence and gender asymmetry increases with age and hanging is a frequently employed method of suicide by children. Compared to adolescents who die by suicide, lower rates of psychopathology are evident among child suicides and children consume alcohol less frequently prior to suicide. Parent-child
6
conflict appears to be a salient precipitating factor for children. In addition, previous suicidal behaviour is a pertinent factor in child suicide.
DISCUSSION Demographics Suicide incidence increases with age. Shaffer and colleagues (1996) suggested that this
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increase may be partly explained by developmental trajectories of important risk factors, such as psychopathology, which is more common in later adolescents. Some gender disparity seems to exist in regards to child suicide, with studies reporting that more suicide deaths occur among male children (Beautrais, 2001b; Freuchen, Kjelsberg & Grøholt, 2012a). However, Shaffer (1996) argues that gender asymmetry becomes more apparent with increasing age. Gender-related method preferences may be an underlying reason for the observed gender disparity, with males significantly more likely to use more lethal methods of suicide compared to females (Brent, Baugher, Bridge, Chen & Chiappetta, 1999; Shaffer, 1974).
Prior research has shown that suicide within Indigenous populations is proportionately more frequent than in non-Indigenous populations (De Leo, Sveticic, Milner & McKay, 2011), and this aspect is particularly visible in children. In a 10-year retrospective study, Beautrais (2001b) examined the epidemiology of New Zealand children who had died aged less than 15 years. She found that Indigenous children predominated child suicide with almost 60% of suicides occurring among Maori’s.
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Suicide Circumstances Of the ten studies (out of 12) which identified predominant suicide method, children were found to use hanging most frequently in five studies. A number of geographical and temporal variations were observed. For example, in the USA, firearm suicides (Brent et al., 1999; Coskun, Zoroglu & Ghaziuddin, 2012; Weinberger, Sreenivasan, Sathyavagiswaran & Markowitz, 2001) were found to surpass hanging cases, while
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jumping from a height was most common in Hong Kong (Lau, 1994) and Singapore (Loh, Tai, Ng, Chia & Chia, 2012). These characteristics mirror older cases in those countries. Access to guns has been identified as an additional and pertinent environmental factor in suicide risk. Miller and colleagues (2002) found a positive and statistically significant association between gun availability and suicide in children aged 5-14 years in the USA. Results suggested that children who lived in states with the highest access to guns were two-times more likely to die from suicide and, importantly, seven-times more likely to use a firearm (Miller, Azrael & Hemenway, 2002). Almost forty years ago, Shaffer (1974) reported that the most common method employed by children was carbon monoxide poisoning, a leading suicide method in England and Wales at that time (Kreitman, 1976). In studies that included age-group comparisons, children were significantly more likely to die by hanging than their older counterparts who used more varying methods (Grøholt, et al., 1998; Hoberman & Garfinkel, 1988). Suicide site for children was most frequently the child’s usual residence. Interestingly, Freuchen and colleagues (2012a) found female children more frequently suicided within their home (67%), compared to male children (33%), who more frequently died ‘elsewhere’ (47% compared to 25% of females).
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Individual Factors Personality Traits Several personality traits appear to be characteristic of children who died by suicide. In his classic study, Shaffer (1974) examined all suicides of children younger than 15 years of age in England and Wales that had occurred between 1962 and 1968. In his final sample of 30 children (70% male, 30% female), Shaffer (1974) systematically reviewed
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coroner reports, educational records, medical and psychiatric records and social service records when applicable. Shaffer’s (1974) study illustrated two distinct “personality stereotypes”:
a)
Children, who were exceedingly intelligent, socially isolated, with mothers who
had psychiatric issues; and, b)
Children who were aggressive, mistrustful, and sensitive to criticism.
Similarly, Hoberman and Garfinkel (1998) reported that, compared to adolescents who had died by suicide, children were more likely to be described as angry, nervous and impulsive. In addition, children were reported as being more withdrawn, passive and uncommunicative compared to adolescents who had died by suicide (Lau, 1994). However, the generalisability of these studies is limited due to the small samples involved and it is unknown if these traits are characteristic of all children and adolescents in these countries. More recently, Freuchen and colleagues (2012b) found children who died by suicide were significantly more ‘vulnerable and touchy’ and ‘impulsive and temperamental’ compared to children who died by accidental deaths. There was also a
9
tendency for children who died by suicide to be described as ‘worried’ compared to those children who died in accidents, though this failed to reach significance.
Mental Health Or Behavioural Difficulties Adult suicide has been shown to commonly occur in the context of a pre-existing (and/or co-morbid) mental health disorders (Bertolote, Fleischmann, De Leo & Wasserman,
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2004; Cavanagh et al., 2003). However, children who die by suicide have lower rates of psychopathology. In the majority of reviewed studies, up to one third of children who died by suicide had a detectable mental health issue at time of death (Beautrais, 2001b; Freuchen et al., 2012a, Freuchen, Kjelsberg, Lundervold & Grøholt, 2012b). In contrast, Brent and colleagues (1999) found a greater prevalence of psychopathology, reporting that 60% of children who died by suicide met the criteria for psychiatric diagnosis. However, in this study the sample of children who died by suicide was a bit older (up to 16 years old).
Specifically, children with affective disorders, disruptive disorders/conduct disorders, and substance abuse disorders may be more likely to exhibit suicidal behaviour than children without these psychiatric difficulties (Brent et al., 1999; Freuchen et al., 2012a, Freuchen et al., 2012b; Grøholt et al., 1998). However, these disorders are more frequent in suicide cases of adolescents (Grøholt et al., 1998; Loh et al., 2012; Marttunen, Aro, Henriksson & Lönqvist, 1991; Shaffer et al., 1996). Brent and colleagues (1999) found that psychopathology, particularly substance abuse (single diagnosis or in the context of comorbidity with mood disorders) was found more frequently, and conveyed a higher
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suicide risk in adolescents compared to children. The prevalence of developmental disorders, specifically Attention Deficit Hyperactivity Disorder (ADHD) was relatively low (Grøholt et al., 1998; Marttunen et al., 1991; Shaffer et al., 1996). However, a literature review found that young people, particularly males, with ADHD have significantly higher risk of suicide (James, Lai & Dahl, 2004).
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Contact With Services Only three studies reported whether children had received mental health evaluation or treatment prior to death. Overall, Beautrais (2001b) reported that less than one fifth (16.4%) of children had been in contact with services in the year prior to death. Furthermore, contact with services was more common in female children (29.4%) than in males (11.4%). In the study by Freuchen and colleagues (2012b), children who died by suicide received help from school psychology services or child and adolescent psychiatry services in a similar manner (17% and 12% respectively). Interestingly, contact with services was similar for children who died in accidents (Freuchen et al., 2012b). In a Norwegian study, Grøholt and colleagues (1998) reported that over a quarter of children (29%) had received psychiatric treatment (compared to 23% of adolescents) prior to death.
Prior Suicidal Behaviour Children who died by suicide were found to have made a previous suicide attempt significantly more frequently compared to children who died in accidents (Freuchen et al., 2012a) and living control groups (Brent et al., 1999; Freuchen et al., 2012b). Between
11
one-fifth and a little over one-third of children have made a prior suicide attempt (Brent et al., 1999; Loh et al., 2012; Weinberger et al., 2001). In contrast, Freuchen and colleagues (2012a) found that only 12% of children in their sample had previously attempted suicide. Nonetheless, this finding was significant in comparison to children who died in accidents, implicating prior suicide attempt as an important risk factor. A prior suicide attempt has been found to be significantly more likely in female children
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compared to male children (Weinberger et al., 2001) and in children who leaved suicide notes compared to those who do not (Freuchen & Grøholt, 2013).
Moreover, suicidal children aged twelve years and younger, have been found to think and dream about death, and this preoccupation with death has been found to be significantly correlated with the degree of lethality in subsequent suicidal behaviour (Pfeffer, Conte, Plutchik & Jerrett, 1979). Indeed, Freuchen and colleagues (2012a) found that almost half of the children in their study who had died by suicide had previously displayed an interest in suicide. These findings suggest that suicidal communication in any form among children would need to be taken seriously, requiring immediate attention. Compared to adolescents, children have been found to be significantly less likely to have expressed prior suicide ideation and made suicide attempts (Grøholt et al., 1998; Hoberman & Garfinkel, 1988). However, parents indicated that their children displayed altered behaviour prior to suicide (Freuchen et al., 2012).
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Family Related Factors Family Psychopathology Psychopathologies in the family, such as parental mood and personality disorders and substance abuse, have been demonstrated to increase child and adolescent risk for nonfatal suicidal behaviour (King, 2009; Pfeffer, Jiang & Kakuma, 2000; Pfeffer, Normindin & Kakuma, 1994). Evidence of a relationship between fatal suicidal behaviour in children
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and presence of psychiatric conditions in the family is lacking. Only one study here reviewed addressed mental health issues within the family. Shaffer (1974) found that over half of the children who died by suicide had family members experiencing psychiatric problems; however these problems also included suicide attempts made by parents or siblings of children (who had died by suicide). King (2009) points out that future research is required in order to delineate the mediating influence that shared genetic risk for psychopathology and the impact of negative family environment have on the familial transmission of both psychopathology and suicidal behaviour.
Family Suicidality Previous suicidal behaviour within the family has been demonstrated to be a predictive factor for suicidal behaviour (King, 2009; Pfeffer et al., 1994). Thirteen per cent of the children who had died by suicide in the Shaffer’s study (1974) had had a suicide attempt by a family member. Compared to children who had died in accidents, children who died by suicide were significantly more likely to have been exposed to a suicide within their community or family (2% vs. 43% respectively; Freuchen, Kjelsberg & Grøholt, 2012a).
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Brent and colleagues (2002) examined the idea of the familial transmission of suicidal behaviour among depressed adults who had attempted suicide (defined as an action made with intent to die which resulted in medical evaluation or treatment) and depressed adult non-attempters and their respective biological children. While children younger than 15 years of age were not examined separately in their analysis, the overall results suggested that children who had parents with a history of suicide attempts had a “6-fold increased
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risk for suicide attempt, relative to offspring of non-attempters” (Brent et al., 2002, p. 805). Furthermore, in a reanalysis of the same data, children who had a parent and sibling with previous suicidal behaviour were found to be at a heightened risk for suicidal behaviour at an earlier age than children without the presence of suicidal behaviour in their family (Brent et al., 2003). More recently, Spiwak and colleagues (2011) found that people exposed to both suicide attempt and suicide of a parent or guardian during childhood were significantly more likely to self-report a suicide attempt of their own than individuals without such exposure. Furthermore, these significant findings remained after the authors controlled for demographic variables, psychiatric disorders and adverse childhood events. Importantly, this study was conducted with a large sample (N = 34,653).
Parental Divorce Beautrais (2001b) found that almost half of the children who died by suicide lived in single parent or stepparent families. The implications of a non-intact family were not replicated in Norway in studies by Grøholt and colleagues (1998) and Freuchen and colleagues (2012b), who found that children who died by suicide more often lived with
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both biological parents (64% and 71%, respectively). Arguably, any association between parental separation/divorce and suicide is greatly mediated by other psychosocial factors (Gould, Greenberg, Velting & Shaffer, 2003).
Parent-Child Relationship Communication between parents and children who died by suicide was found to be
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significantly poorer compared to children who died by accidents (Freuchen et al., 2012b). In additional analyses comparing suicide note writers and non-note writers from data obtained in their psychological autopsy study, Freuchen and Grøholt (2013) found a nonsignificant trend toward note writers having poorer communication with parents compared to those who did not leave a suicide note. Gould and colleagues (2003) highlighted the need to consider the potentially negative implications of an individual’s underlying psychological difficulties on relationships and communication. However, the association between poor communication with parents and suicide has been demonstrated to persist even when the presence of psychiatric disorders was taken into account (Gould, Fisher, Parides, Flory & Shaffer 1996).
Adverse Life Events And Home Environment A detrimental home environment has the potential to greatly influence suicidality in children (Tishler et al., 2007). Adverse events, such as physical and sexual abuse, witnessing or experiencing violence, and a history of maltreatment are all potential risk factors for suicidal behaviour (Tishler et al., 2007; Séguin, Renaud, Lesage, Robert &
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Turecki, 2011). A lifetime history of abuse was found to convey a much increased risk for suicide in children (Brent et al., 1999).
The most commonly reported precipitant among children who died by suicide was family conflict, in particular parent-child conflict. Parent-child conflicts seem to be a salient precipitating factor for children (Brent, et al., 1999; Beautrais, 2001b; Coskun et al.,
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2012; Freuchen et al., 2012a; Hoberman & Garfinkel, 1998; Loh et al., 2012; Weinberger et al., 2001). These conflicts were often deemed as ‘minor’ by parents at the time (Freuchen et al., 2012a). Parent-child conflict also appears more frequently in cases of children compared to adolescents, who more frequently experience romantic relationship issues (Coskun et al., 2012; Grøholt et al., 1998; Hoberman & Garfinkel, 1988; Loh et al., 2012).
Other psychosocial predictive factors associated with child suicide include emotional interpersonal loss caused by death or separation (Beautrais, 2001b; Freuchen et al., 2012a; Freuchen et al., 2012b). Of note is that some precipitants occurred in the context of a real or perceived disruption or transition in the child’s living or educational arrangements or in the context of serious family issues (Beautrais, 2001b).
Socio-Environmental And Contextual Factors School Related Factors School-related psychosocial predictive factors include bullying, negative peer pressure, and perceived or real school performance problems. Compared to a living control group,
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children who died by suicide were found to be have experienced significantly more bullying; however, no significant differences were found compared to children who died by accidental death (Freuchen et al., 2012b). Bullying is a detrimental problem affecting some children and experiences of bullying has been implicated in suicide attempts later in life (Klomek et al., 2009). Klomek and colleagues (2009) found that boys who experienced bullying at age 8 displayed an increased risk of suicide (up to age 25 years)
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if they were also experiencing depression or conduct disorder. For girls, this increased risk remained irrespective of these mental health difficulties.
Perceived or real school performance problems were another important precipitant identified in child suicide (Coskun et al., 2012; Hoberman & Garfinkel, 1988; Loh et al., 2012). Compared to adolescents who died by suicide, children who died by suicide were significantly more likely to experience academic failure or difficulties as a precipitating event to suicide (Hoberman & Garfinkel, 1988; Loh et al., 2012). In addition, Shaffer’s (1974) study revealed that an absence from school was a common occurrence in children younger than 15 years old who died by suicide. Although children were not analysed separately, in a study conducted by Gould and colleagues (1996), children and adolescents who were neither employed or at school at the time of their death had a heightened risk for suicide compared to a control group. These findings suggest that social isolation may be associated with suicidal behaviour (Gould et al., 1996).
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Alcohol Consumption Prior To Suicide In addition to overall alcohol and substance abuse being less common in children compared to adolescents (Marttunen et al., 1991; Shaffer et al., 1996) children have been demonstrated as consuming alcohol significantly less frequently prior to death compared to adolescents (Brent et al., 1999; Grøholt et al., 1998).
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Suicide Notes There is some empirical evidence suggesting that children do not customarily leave suicide notes (Batalis & Collins, 2005; Schmidt, Müller, Dettmeyer, & Madea, 2002). Freuchen and Grøholt (2013) procured 23 suicide notes (left by 18 children) during a psychological autopsy on 42 children who had died by suicide. The number of children who left notes was high (43%) compared to findings by Grøholt and colleagues (1998) in a previous Norwegian study (14%). Freuchen and Grøholt (2013) findings are comparable to the findings of Beautrais (2001b; 32.8%), Weinberger and colleagues (2001; 37%) and Loh and colleagues (2012; 50%). The aim of Freuchen and Grøholt (2013) study was two-fold: to assess the differences and similarities between children who left suicide notes and those who did not, and to explore and describe the themes present in the notes. Overall, no differences were revealed for demographic factors, psychiatric wellness, treatment received, stressful life events or circumstances of suicide between children who left suicide notes and those who did not. Children who left suicide notes were, however, significantly more likely to have previously attempted suicide and were significantly more likely to display altered behaviour prior to suicide. Altered behaviour included being described as more joyful, affectionate, relaxed, tense or silent.
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Freuchen and Grøholt (2013) argued that the suicide notes gave an overall impression of higher suicidal intent compared to non-note writers, extending beyond the presence of a suicide note. Several themes were described by the authors, chiefly explanations for the suicide, declarations of love and post-humorous instructions.
CONCLUSION
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Suicide is a complex and multifaceted behaviour, which has not yet been extensively examined among children. Existing studies have especially been limited by relatively small sample sizes and conducted in developed countries. The retrospective nature of the PA case series, and the potentially confounding influence of the passing of time on the reliability and validity of participant recall also represent a potential limitation (Brent, Perper, Kolko & Zelenak, 1988). The parallel inclusion of a comparison group in studies would minimise this potentially confounding factor.
In addition to psychiatric factors, an interaction of psychosocial, environmental, and contextual factors seem to be associated with suicide in childhood. Evidence-based knowledge of the myriad aspects of child suicide is crucial to the understanding of child suicide and the development of targeted suicide prevention. There are few recent systematic literature reviews focusing on evidence in suicide prevention activities in children and adolescents (e.g., De Silva et al, 2013). Recognition, referral and subsequent effective treatment of psychiatric difficulties and suicidal behaviour are essential. However, lower rates of psychopathology among children who die by suicide highlights the importance of other prevention initiatives such as restriction of means and psycho-
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education for parents, peers and school staff. In addition to understanding and mitigating the risk factors associated with child suicide, a better understanding of protective factors is required.
COMPETING INTERESTS
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Nothing to declare.
FUNDING This study is supported by the Australian Research Council Linkage grant “Trends and predictors of suicide in Australian children” (LP0990918). We would like to acknowledge our partners: the Commission for Children and Young People and Child Guardian (CCYPCG), Queensland Department of Justice, Office of State Coroner (OSC); Queensland Health (QH) and; Department of Education, Training and Employment (DETE).
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Table 1. Studies examining suicide in children 14 years and younger Study
Country and Sample (Age Comparison Suicide Timeline
[years,
group (Age
range] and
[years,
n)
range] and
Precipitant
Psychiatric or behavioural
method
difficulties
Prior suicidal behaviour
Other important findings
--
Number of suicides seems to be increasing
n) Retrospective Case Studies Beautrais (2001b) New Zealand
9-14
No
Hanging
Argument with 23% Mental health problems
n = 61
comparison
(78.7%)
a family
within a year of death
Incidence of suicide increases with age for
member
1 in 3 known to school, mental
both males and females, with twice as many
(70.5%) and/or
health and/or social welfare
suicides among 14 year olds (57.4%) than
disciplinary
authorities
13 year olds (26.2%)
issue (26.2%)
Overall, 16.4% had contact
Majority of suicides were male (72.1%)
Bereavement
with services in year prior to
57.4% of individuals who suicided were
of immediate
death; more commonly
Maori (64.7% of females and 54.6% of
family (1 in 7)
females (29.4%; compared to
males who suicided were Maori)
11.4% of males)
Majority occurred in deceased residence
group
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1989-1998
(86.9%) 32.8% left suicide notes 9.8% family history of suicide 45.9% lived in single parent or stepparent families followed by 32.8% in nuclear families Coskun, Zoroglu
Turkey &
